How Models Work: Care Coordination from an IT Perspective

How Models Work:

Care Coordination from an IT

Perspective

DISCLAIMER: The vi ews and opinions expressed i n this presentation are those of the author a nd do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Disclosure

Steve Davis, D.O. Roberta Sniderman

Has no real or apparent

conflicts of interest to report.

Today‟s Objective

 Identify the clinical care components of a successful ACO requiring IT support

 Identify the information technology components utilized to support the ACO

 Understand how IT can be utilized in real time clinical and analytical support of care coordination and financial

strategies

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HealthCare Partners Medical Group National Delivery System

• California

– HealthCare Partners LLC – HealthCare Partners

Medical Group

– HealthCare Partners IPA • Florida

– JSA • Nevada

– Pinnacle Health Care Systems

– Summit Medical Group – Fremont Medical Group – Rainbow Medical Group – In Patient Physician

5 •Physician Led, Professionally Managed

•Global Capitation Predominates

•Centrally Coordinated

•Regionally Driven

•Strong Medical Management Infrastructure

•Robust Business Support Units

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Over 7,000 physicians

Over 1,000,000 managed patients Over 175,000 Medicare Advantage 600,000 commercially insured full risk global capitation

An unmeasured number of attributable private, FFS, and

Our Vision :

“We are altering the cost curve permanently in a positive direction.”

Zan Calhoun

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HCP ACO History

• Selected as one of the five organizations for Dartmouth-Brookings National

Commercial ACO pilot

 Delegations in May of 2012  70,000+ Patients

• Selected as three of the 32 Medicare Pioneer ACO pilots including our Florida and Nevada divisions

 Pioneer program began January 1, 2012  77,000+ patients

10 Fragmentation Adversarial relationships Focus on “doing” One-to-one care Gatekeeper

Perverse financial incentives Focus on volume/intensity

Current System ACO System

Integration Cooperation

Focus on managing a population Team-based care

System management Aligned incentives

Focus on quality and efficiency

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Capacity Patients Processes Physicians

Health Information Technology Health Risk Assessment Improved Care Coordination Chronic Disease Management Point of Care Reminder Reduced Waste Aligned Incentives Access to Timely Data

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An Effective ACO:

1. Better alignment of

physician, hospital, and member incentives with desired results

2. Care management interventions to prevent medical problems from

escalating

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A small ship

struggles

in a big sea.

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An ACO needs

critical mass to

Proactive Population Management

The continuous ‘Virtuous Cycle’ of Improved care and outcomes is at the heart of HCP’s proactive population management.

• Better Care • Better Quality • Better Efficiency

• Better Patient Experience

The HCP Care Team

Approach

teams of clinicians support HCP clinical programs.

High Risk Programs: •Home Care

•ESRD

•Comprehensive Care Center •Post-Acute Comprehensive Care

Disease Management Programs: •Diabetes

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Care Management Interventions

• Hospitalist program

• Preventive care and health coaching

• Point-of-Care reminders • Patient and physician

education

Programs Overlap

Health Support No or Low Claims

Care Support

Intense & Frequent Claims

Outcome

Risk Low High

Healthy Lifestyle Issues Chronic Catastrophic Terminal

Health Promotion, Wellness, Primary Prevention Education and Information Sharing

Screening and Secondary Prevention

Decision Support

Disease Management

Care Management

re-admission within 30 days • Reduction in hospital

Today‟s Objective

 Identify the clinical care components of a successful ACO requiring IT support

 Identify the information technology components utilized to support the ACO

 Understand how IT can be utilized in real time clinical and analytical support of care coordination and financial

strategies

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Care Management

Interventions

“Every system is perfectly designed to

achieve exactly the results it achieves. If we want new results—and we do— we need a new system.”

-Donald Berwick

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Technology

ACOs must invest in the appropriate

technology to enable economic

incentives and care management

interventions.

Chronic Care Model HCO Core Components

•Clinical information systems (electronic health records)

•Decision support information •Delivery system design

•Self-management support

25 • Data Warehouse: Over 20 years of

clinical and financial information

• Practice Management systems

• Multiple EMR systems

HealthCare Partners

Technology Systems

• Inpatient Tracking System

• Clinical Care Management(CCMIS)

• Referral Management System

26 • Physician Information Portal

• HCC, P4P, Star measurement and support

• Patient and practice management information

• Care Guidelines and Educational Resources

• Patient Online Portal

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What do you need?

• Ability to Identify ACO Patients:

Practice Management System (GE/IDX)

• Morphing system to make an ACO (Fee for Service or Medicare) patient look like HMO patient for triggering activity, reporting

capabilities, and population management

• Utilizing our enrollment interface to load ACO patients

• Eligibility Member Benefits shell built for claim, DME coverage, office and specialist copay, etc. • Modifying current system HMO requirements to

What do you need?

• Ability to Identify ACO Patients By Others:

In-Patient Tracking System (Patient Keeper)

• Hospital admissions would be best if we can identify patient in the ambulance on the way to the hospital vs. 2 days later

• If our Hospitalist can meet the patient in the ER then we can potentially change care

• Hospitals need a way (and a reason) to identify an ACO patient and who is responsible for the patient (low tech stickers) to trigger ADT interface

• Attributed members show up in core hospital then hospitalist program kicks in if alerted by admitting provider

• Once identified, ADT HL7 Interfaces, document interfaces, faxes, required to communicate

What do you need?

• Ability to provide Discharge Planning

for ACO Patients:

InPatient Workflow System (K2) • Route patient and activity • Medication Reconciliation • Admit activity

• Post Discharge Appointment • Fax Routing

What do you need?

• Ability to track post discharge:

• Ability to suggest another care setting

• Coordinate follow-up visits with PCP within 48 hours

• Order DME

• Phone call follow-ups

• Get the patient to the right specialists • Enroll patients in High Risk Clinics

• Manage Referral Process

Referral Management System (HCP RMS)

– For tracking and managing medical management

– Hospital admissions attempt to encourage core hospital utilization, HCP surgeons, to obtain

better outcomes

– Physician and facility contracting for in network access utilizing PPL flag at the ACO level

– System fed HMO Patients for attribution – IPA docs will then know that this a ACO

enrollment to PCP or Specialist

• Provide Care Management

Clinical Care Management (HCP CCMIS)

– Hospital data passed to in house system for chronic Care Management

– Manage transition of care upon discharge to establish action plan for SNF, Home Health Care, High Risk Clinics and Programs, DME Equipment, office visit, as required to avoid readmission

Complex Care Management and

Disease Management

• Programs

• Care Manager History • Goals & Actions

• Problems & Barriers • Labs

• Assessments • Tasks

• Appointment History • Referral History

• Attachments

• Facility Visits / Inpatient Visits • Claims

• Electronic Health Record Meeting

Meaningful Use by 2012

EHR (Allscripts, Epic, NextGen) • Ability to attest for Meaningful

Use for 50% of all Primary Care Providers by the end of 2012 • Capture elements for Quality

Measure Reporting Requirements • Provide clinical data for

coordinated delivery of care

amongst different clinical systems

• Clinical Data Capture

Electronic Health Record (EHR)

– Reviewing and modifying to assure EHR (Allscripts, Epic, and NextGen) can capture Meaningful Use criteria

– Extract all Quality Measure Standards into a Data Warehouse for reporting to CMS and other ACOs

– 50% of Primary Care Providers Attest for Meaningful Use in 2012

– Share clinical information amongst all patient care providers

• Collaboratively Share Clinical Content Clinical Data Sharing (HCP Clinical Viewer)

– Central repository of clinical content for all patients

– Collaboration for EHR (Allscripts, Epic, and NextGen)

– All Problems, Meds prescribed and filled, Allergies, Labs, Radiology, EKG‟s, Vitals, etc. – Hospital data I.e.: Discharge Summary, H&P,

ADT, Consultations, etc.

– Consult Notes, scanned documents, End of Life Wishes, etc.

– All encounter data: Procedures, referrals, diagnosis, etc.

What do you need?

• Patient Engagement and Patient Experience

Patient Portal (HCP)

– Need to have patient feel they Won the Lottery by becoming an ACO member

– Secure email with provider and/or office – Lab views

– Appointment scheduling, Bill Payment

– Patient Education and Demographic Updates – eMobile connectivity

What do you need?

• Communication, Communication, Communication

Physician Information (www.hcpaco.com)

– Ability to provide information on overview of an ACO

– Q&A‟s for providers

– State specific regulations and guidelines – How to contact key resources

– Telecommunication additions for direct dialing access to ACO questions for providers,

Today‟s Objective

 Identify the clinical care components of a successful ACO requiring IT support

 Identify the information technology components utilized to support the ACO

 Understand how IT can be utilized in real time clinical and analytical support of care coordination and financial

strategies

Real Time Clinical

• Clinical data sharing when patient presents with relevant clinical data in a useable format

• Real time notification for hospital admissions

• Real time Referral and Authorization for routing patients in network

• Patient identification and

communication of changing care delivery models

• Analysis of the provision and financing of health care services

Episodic Treatment Groups® (Ingenix ETG)

– Measuring and comparing healthcare providers based on the cost of treating patient episodes – Measuring health care demand, including the

prevalence of clinical conditions and the services and costs involved in their treatment

– Establishing disease management strategies,

including tracking organizational performance and trends around specific diseases and episodes

• Predictive Modeling and Risk Stratification Data Analysis

– Identify sickest portion of patient population to enroll them into appropriate care programs

– Identify likely events – ER visit, clinical event, drug change

– Utilizing CMS Hierarchical Condition Coding (HCC) Risk Adjust Factor (RAF) scores to identify patients at risk

• Disease Management

Analytics (HCP Reporting Services)

– All systems pass information to Data

Warehouse for Analytics and Decision Support Reporting

– Disease Registries populated to identify who falls into which programs proactively

– Determination of who should you touch with limited resources

– Web based, Self Service

Clinical Data, Clinical Tools

Disease Registries for every HCP physician to better understand the make up of his or her patient panel

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• Quality Measures Reporting

CMS 2012 Program Analysis - ACO Quality Measures

– 33 required quality measures that are part of the quality performance standard

– Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient experience survey measures

– Claims-based measures

– Electronic Health Record (EHR) Incentive Program measure – Group Practice Reporting Option (GPRO) web interface quality

measures that are required for purposes of ACO participants earning a Physician Quality Reporting System (PQRS) incentive under the Medicare Shared Savings Program.

• Quality Care and Patient Management

Physician Information Portal (HCP PiP)

– Ability to provide intervention reports by HCC Category, HCC Physician Pursuit List, High Risk Pursuit List, P4P Category, STAR Measures, etc. to assure quality

outcomes

– Performance Measures for each physician for HCC

summary, recapture rate, P4P scores, STAR Scores, etc. – Patient Management: lists, schedules, panels, etc.

– Care Guidelines and Patient Education Material

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Today‟s Objective

 Identify the clinical care components of a successful ACO requiring IT support

 Identify the information technology components utilized to support the ACO

 Understand how IT can be utilized in real time clinical and analytical support of care coordination and financial

strategies

Outside Health IT Control:

• CMS has no way to alert when an ACO patient is in the hospital

• Medicare card does not identify ACO patient or belonging to HCP • ACO patients can go anywhere

they want, to any provider they want, any specialist, any hospital

• Hospitals have no incentive to alert HCP of PPO ACO patient

• Providers have little incentive to request referral authorization for PPO patient

Under Health IT Control:

• Systems are not setup for every potential „Referred To‟ provider • HCP does not have all claims and

clinical data on ACO creating a dependency on data dumps from CMS or provider

• Stale data for analyzing and identifying key patients to target intervention programs is difficult to operationalize

• Clinical System Vendors are not to a point of collaboration with each other

Sometimes low-tech is OK:

• When cost of system

modifications are greater than potential earnings

– Anthem real time referral system modification estimated at $1million – Low tech solution for $150k to meet

the 10 referrals / day

• Live communication with patients shown to be more effective.

• Sometimes people just need to communicate to people

Pretty please provider, can we see your patient?

Pretty please patient, will you share your data, see our

providers, and use our

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“We have really good data that

shows when you take

patients and you really

inform them about their

choices, patients make more

frugal choices. They pick

more efficient choices than

the healthcare system does.”

-Donald Berwick

Off on the wrong foot!

•Identify the problem and own it organization wide •Address it rapidly

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Keys To ACO Success